Personal Information *

First Name

Last Name

Date

MM

DD

YYYY

Phone Number *

Country

(###)

###

####

Emergency Contact ( Name & Phone number)

(###)

###

####

Medical Background

Hypothyroidism

Migraines

Autoimmune Disorder

Chronic Pain

Anxiety / Depression

Current Symptoms

Fatigue

Digestive Issues

Hormonal Imbalance

Poor Sleep

Skin Concerns

Stress & Anxiety

Treatment Preferences

Red Light Therapy

Lymphatic Massage

Herbal Remedies

Aromatherapy

Energy Balancing / Reiki

Scalp Therapy